Customer 7 Digit Account Number
*
Date
*
-
Month
-
Day
Year
Date
Name (for refund check)
*
First Name
Last Name
Address (for refund check)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Your Email Address
*
example@example.com
Reason for requesting a refund
*
Overpayment
Adjustment to Account
Other
*
I/We indemnify Pittsburgh Water for any loss that may be incurred by acceding to this request.
Electronic Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Continue
Continue
Should be Empty: